The “Black Fungus” in India: The Emerging Syndemic of COVID-19–Associated Mucormycosis

What you will not know about this body is that

Allopurinol Initiation and All-Cause Mortality Among Patients With Gout and Concurrent Chronic Kidney Disease: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 175, No 4

Background: Two recent randomized clinical trials of escalating doses of allopurinol for the progression of chronic kidney disease (CKD) reported no benefits but potentially increased risk for death. Whether the risk could occur in patients with gout and concurrent CKD remains unknown. Objective: To examine the relation of allopurinol initiation, allopurinol dose escalation, and achieving target serum urate (SU) level after allopurinol initiation to all-cause mortality in patients with both gout and CKD. Design: Cohort study. Setting: The Health Improvement Network U.K. primary care database (2000 to 2019). Participants: Patients aged 40 years or older who had gout and concurrent moderate-to-severe CKD. Measurements: The association between allopurinol initiation and all-cause mortality over 5-year follow-up in propensity score (PS)–matched cohorts was examined. Analysis of hypothetical trials were emulated: achieving target SU level (<0.36 mmol/L) versus not achieving target SU level and dose escalation versus no dose escalation for mortality over 5-year follow-up in allopurinol initiators. Results: Mortality was 4.9 and 5.8 per 100 person-years in 5277 allopurinol initiators and 5277 PS-matched noninitiators, respectively (hazard ratio [HR], 0.85 [95% CI, 0.77 to 0.93]). In the target trial emulation analysis, the HR of mortality for the achieving target SU level group compared with the not achieving target SU level group was 0.87 (CI, 0.75 to 1.01); the HR of mortality for allopurinol in the dose escalation group versus the no dose escalation group was 0.88 (CI, 0.73 to 1.07). Limitation: Residual confounding cannot be ruled out. Conclusion: In this population-based data, neither allopurinol initiation, nor achieving target SU level with allopurinol, nor allopurinol dose escalation was associated with increased mortality in patients with gout and concurrent CKD. Primary Funding Source: Project Program of National Clinical Research Center for Geriatric Disorders.

Resuming In-Person Learning: Safe and Imperative

Measuring the COVID-19 Mortality Burden in the United States: A Microsimulation Study: Annals of Internal Medicine: Vol 174, No 12

Background: Fully assessing the mortality burden of the COVID-19 pandemic requires measuring years of life lost (YLLs) and accounting for quality-of-life differences. Objective: To measure YLLs and quality-adjusted life-years (QALYs) lost from the COVID-19 pandemic, by age, sex, race/ethnicity, and comorbidity. Design: State-transition microsimulation model. Data Sources: Health and Retirement Study, Panel Study of Income Dynamics, data on excess deaths from the Centers for Disease Control and Prevention, and nursing home death counts from the Centers for Medicare & Medicaid Services. Target Population: U.S. population aged 25 years and older. Time Horizon: Lifetime. Perspective: Individual. Intervention: COVID-19 pandemic through 13 March 2021. Outcome Measures: YLLs and QALYs lost per 10 000 persons in the population. The estimates account for the age, sex, and race/ethnicity of decedents, along with obesity, smoking behavior, lung disease, heart disease, diabetes, cancer, stroke, hypertension, dementia, and nursing home residence. Results of Base-Case Analysis: The COVID-19 pandemic resulted in 6.62 million QALYs lost (9.08 million YLLs) through 13 March 2021, with 3.6 million (54%) lost by those aged 25 to 64 years. The greatest toll was on Black and Hispanic communities, especially among men aged 65 years or older, who lost 1138 and 1371 QALYs, respectively, per 10 000 persons. Absent the pandemic, 38% of decedents would have had average or above-average life expectancies for their subgroup defined by age, sex, and race/ethnicity. Results of Sensitivity Analysis: Accounting for uncertainty in risk factors for death from COVID-19 yielded similar results. Limitation: Estimates may vary depending on assumptions about mortality and quality-of-life projections. Conclusion: Beyond excess deaths alone, the COVID-19 pandemic imposed a greater life expectancy burden on persons aged 25 to 64 years, including those with average or above-average life expectancies, and a disproportionate burden on Black and Hispanic communities. Primary Funding Source: National Institute on Aging.

Eliminating the “Morbid” in Obesity: A Step Toward More Sensitive Documentation in the Era of Open Notes

Medical Violence

Putting Medicare Spending for COVID-19 Into Perspective

Racial and Ethnic Disparities in Excess Deaths During the COVID-19 Pandemic, March to December 2020

Background: Although racial/ethnic disparities in U.S. COVID-19 death rates are striking, focusing on COVID-19 deaths alone may underestimate the true effect of the pandemic on disparities. Excess death estimates capture deaths both directly and indirectly caused by COVID-19. Objective: To estimate U.S. excess deaths by racial/ethnic group. Design: Surveillance study. Setting: United States. Participants: All decedents. Measurements: Excess deaths and excess deaths per 100 000 persons from March to December 2020 were estimated by race/ethnicity, sex, age group, and cause of death, using provisional death certificate data from the Centers for Disease Control and Prevention (CDC) and U.S. Census Bureau population estimates. Results: An estimated 2.88 million deaths occurred between March and December 2020. Compared with the number of expected deaths based on 2019 data, 477 200 excess deaths occurred during this period, with 74% attributed to COVID-19. Age-standardized excess deaths per 100 000 persons among Black, American Indian/Alaska Native (AI/AN), and Latino males and females were more than double those in White and Asian males and females. Non–COVID-19 excess deaths also disproportionately affected Black, AI/AN, and Latino persons. Compared with White males and females, non–COVID-19 excess deaths per 100 000 persons were 2 to 4 times higher in Black, AI/AN, and Latino males and females, including deaths due to diabetes, heart disease, cerebrovascular disease, and Alzheimer disease. Excess deaths in 2020 resulted in substantial widening of racial/ethnic disparities in all-cause mortality from 2019 to 2020. Limitations: Completeness and availability of provisional CDC data; no estimates of precision around results. Conclusion: There were profound racial/ethnic disparities in excess deaths in the United States in 2020 during the COVID-19 pandemic, resulting in rapid increases in racial/ethnic disparities in all-cause mortality between 2019 and 2020. Primary Funding Source: National Institutes of Health Intramural Research Program.

Thiamine Supplementation in Patients With Alcohol Use Disorder Presenting With Acute Critical Illness: A Nationwide Retrospective Observational Study: Annals of Internal Medicine: Vol 175, No 2

Background: Thiamine supplementation is recommended for patients with alcohol use disorder (AUD). The authors hypothesize that critically ill patients with AUD are commonly not given thiamine supplementation. Objective: To describe thiamine supplementation incidence in patients with AUD and various critical illnesses (alcohol withdrawal, septic shock, traumatic brain injury [TBI], and diabetic ketoacidosis [DKA]) in the United States. Design: Retrospective observational study. Setting: Cerner Health Facts database. Patients: Adult patients with a diagnosis of AUD who were admitted to the intensive care unit with alcohol withdrawal, septic shock, TBI, or DKA between 2010 and 2017. Measurements: Incidence and predicted probability of thiamine supplementation in alcohol withdrawal and other critical illnesses. Results: The study included 14 998 patients with AUD. Mean age was 52.2 years, 77% of participants were male, and in-hospital mortality was 9%. Overall, 7689 patients (51%) received thiamine supplementation. The incidence of thiamine supplementation was 59% for alcohol withdrawal, 26% for septic shock, 41% for TBI, and 24% for DKA. Most of those receiving thiamine (n = 3957 [52%]) received it within 12 hours of presentation in the emergency department. The predominant route of thiamine administration was enteral (n = 3119 [41%]). Limitation: Specific dosing and duration were not completely captured. Conclusion: Thiamine supplementation was not provided to almost half of all patients with AUD, raising a quality-of-care issue for this cohort. Supplementation was numerically less frequent in patients with septic shock, DKA, or TBI than in those with alcohol withdrawal. These data will be important for the design of quality improvement studies in critically ill patients with AUD. Primary Funding Source: National Institutes of Health.